Levels Of Laparoscopic Experience Research Articles

Objective Evaluation of Laparoscopic Experience Based on Muscle Electromyography and Accelerometry Performing Circular Pattern Cutting Tasks: A Pilot Study.

Purpose.The aim of this work is to present a new physical laparoscopy simulator with an electromyography (EMG)/accelerometry-based muscle activity recording system, EvalLap EMG-ACC, and perform objective evaluation of laparoscopic skills based on the quantification of muscle activity of participants with different levels of laparoscopic experience. Methods. EMG and ACC signals were obtained from 14 participants (6 experts, 8 medical students) performing circular pattern cutting tasks using a laparoscopic box trainer with the Trigno (Delsys Inc, Natick, MA) portable wireless system of 16 wireless sensors. Sensors were placed on the proximal and distal muscles of the upper extremities. Seven evaluation metrics were proposed and compared between skilled and novice surgeons. Results. The proximal and distal arm muscles (trapezius, deltoids, biceps, and forearms) were most active while executing laparoscopic tasks. Laparoscopic experience was associated with differences in EMG amplitude (), muscle activity (), hand acceleration (), user movement (), and muscle fatigue. For the cutting task, the deltoid, bicep, forearm EMG amplitude, and user movement significantly differed between experience groups. Conclusion. This pilot study demonstrates that different muscle groups are preferentially activated during laparoscopic tasks depending on the level of surgical experience. Expert surgeons showed less muscle activity compared with novices. EvalLap EMG-ACC represents a promising means to distinguish surgeons with basic cutting skills from those who have not yet developed these skills.

The Artisential® Articulated Laparoscopic Forceps: A Dry Lab Study to Examine Dexterity and Learning Effects in Operators with Different Levels of Laparoscopic Experience

Purpose: The advent of robotic surgery has highlighted the advantages of articulation. This dry-lab study examined the dexterity and learning effect of a new articulated laparoscopic instrument: the ArtiSential® forceps (LIVSMED, Seongnam, Republic of Korea). Methods: A peg board task was designed. Three groups of volunteers with varying levels of laparoscopic expertise were organized to perform the task: expert, intermediate and novice. The participants performed the task using articulated and straight instruments, once before a 30-min training session and once afterwards. The times required to perform the task were recorded. The performances were analyzed and compared between the groups as well as between the straight and articulated instruments. Results: The experts were significantly faster than the novices with both instruments before the 30-min training session (p = 0.0317 for each instrument). No significant time difference was found among the three groups after the 30-min training session. The decrease in the time required to perform the peg-transfer task with the articulated instrument was significantly greater in the novice and intermediate groups (p = 0.0159 for each group). No significant difference in time reduction was observed between the groups with the straight instrument. Regardless of the user, the articulated device was associated with faster task performance than the straight device after 8 hours of training (p = 0.0039). Conclusion: The ArtiSential® articulated device can improve dexterity. A significantly greater learning effect was observed in the novice and intermediate groups in comparison with experts. A plateau in the learning curve was observed after a few hours of training.

Bimanual Fundamentals: Validation of a New Curriculum for Virtual Reality Training of Laparoscopic Skills.

Background. To determine face and construct validity for the new Bimanual Fundamentals curriculum for the Simendo® Virtual Reality Laparoscopy Simulator and prove its efficiency as a training and objective assessment tool for surgical resident’s advanced psychomotor skills. Methods. 49 participants were recruited: 17 medical students (novices), 15 residents (intermediates), and 17 medical specialists (experts) in the field of gynecology, general surgery, and urology in 3 tertiary medical centers in the Netherlands. All participants performed the 5 exercises of the curriculum for 3 consecutive times on the simulator. Intermediates and experts filled in a questionnaire afterward, regarding the reality of the simulator and training goals of each exercise. Statistical analysis of performance was performed between novices, intermediates, and experts. Parameters such as task time, collisions/displacements, and path length right and left were compared between groups. Additionally, a total performance score was calculated for each participant. Results. Face validity scores regarding realism and training goals were overall positive (median scores of 4 on a 5-point Likert scale). Participants felt that the curriculum was a useful addition to the previous curricula and the used simulator would fit in their residency programs. Construct validity results showed significant differences on the great majority of measured parameters between groups. The simulator is able to differentiate between performers with different levels of laparoscopic experience. Conclusions. Face and construct validity for the new Bimanual Fundamental curriculum for the Simendo virtual reality simulator could be established. The curriculum is suitable to use in resident’s training programs to improve and maintain advanced psychomotor skills.

Construct validity of the SurgForce system for objective assessment of laparoscopic suturing skills.

Laparoscopic surgery requires a new set of skill to be learned by the surgeons, of which the most relevant is tissue manipulation. Excessive forces applied to the tissue can cause rupture during manipulation or ischemia when confronting both sides of the tissue. The aim of this study is to establish the construct validity of the SurgForce system for objective assessment of advanced laparoscopic skills, based on the force signal generated during suture tasks, and the development of force parameters for evaluating tissue handling interaction. The SurgForce system, a tissue handling training device that measures dynamic force, was used to capture the force generated by surgeons with different levels of laparoscopic experience. For construct validity, 37 participants were enrolled in this study: 19 medical students, 12 residents of surgical specialties and 6 expert surgeons. All participants performed an intracorporeal knotting suture task over a synthetic tissue pad with a laparoscopic box-trainer. The force performance of the participants was analyzed using 11 force-based parameters with the application of the SurgForce system. Statistical analysis was performed between novice, intermediate, and expert groups using a Kruskal-Wallis test, and between the pairs of groups using a Mann-Whitney U-test. Overall, 9 of the 11 force-related parameters showed significant differences between the three study groups. Results between the pairs of groups presented significant differences in 5 force parameters proposed. Construct validity results demonstrated that the SurgForce system was able to differentiate force performance between surgeons with different levels of laparoscopic experience. The SurgForce system was successfully validated. This force system showed its potential to measure the force exerted on tissue for objective assessment of tissue handling skills in suturing tasks. Furthermore, its compact design allows the use of this device in conventional laparoscopic box-trainers.

2660 Bimanual Fundamentals: Validation of A New Virtual Reality Curriculum for Advanced Laparoscopic Skills Training

Study Objective To determine face- and construct validity for the new ‘Bimanual Fundamental Curriculum’ for the Simendo Virtual Reality Laparoscopy Simulator and prove efficiency as a training and objective assessment tool for surgical resident's advanced psychomotor skills. Design Prospective multi-center cohort study. Power calculation was performed. The curriculum was new developed for more experienced laparoscopic trainees. It consists of five exercises, focused on bimanual precision training. Setting Two University hospitals in the Netherlands. Patients or Participants Three groups according surgical experience: medical students (novices, N=17), residents PGY 4-6 (intermediate, N=15) and laparoscopic specialists (experts, N=15) in the field of gynecology, surgery and urology. Interventions Participants (N=47) performed the five exercises three consecutive times. The first run was used as introduction and the second and third run were used for analysis. Intermediates and experts filled out a questionnaire afterwards, regarding reality of the simulator and training goals of each exercise. Statistical analysis of performance was performed between novices, intermediates, and experts. Parameters task time, collisions/displacements, and path length were compared. Additionally, a total performance score was calculated for each participant. Measurements and Main Results Face validity scores regarding realism and training goals were overall positive (median scores of 4 on a 5-point Likert scale). Participants felt the curriculum was a useful addition to the previous curricula (71.9%) and the simulator would fit in their residency programs (96.8%). Construct validity results showed significant differences on the great majority of measured parameters between groups. Experts outperformed intermediate is the three most difficult exercises. The simulator is able to differentiate between performers with different levels of laparoscopic experience (p Conclusion Face- and construct validity for the new Bimanual Fundamental curriculum for this virtual reality simulator could be established. The curriculum is suitable to use in resident's training programs to improve and maintain advanced psychomotor skills.

Laparoscopic specimen retrieval and attitudes towards morcellation: a questionnaire survey of gynaecology consultants in the United Kingdom

The aim of this study was to evaluate the practices of laparoscopic specimen retrieval among Gynaecologists in the United Kingdom and to determine any variation in practice. A survey of Consultant Gynaecologist members of the British Society of Gynaecological Endoscopy (BSGE) was conducted using Survey Monkey™. Of the 460 registered consultants, 187 (40%) responded to the questionnaire. Sixty-two percent (62%) of the respondents considered themselves to be advanced laparoscopic surgeons whilst 34% considered themselves to be intermediate laparoscopic surgeons. The umbilical port was the most commonly used port for specimen retrieval and it was used to remove 49% of ectopic pregnancies, 43% of ovarian cysts and 43% of endometrioma. Most respondents would not insert an extra port or extend the existing port just for the retrieval of a specimen. The level of laparoscopic experience and the gender did not affect the method of specimen retrieval in cases of ectopic pregnancies, endometrioma and ovarian cysts (p value >.05, not significant). The majority of respondents used power morcellation for a laparoscopic myomectomy (85% of respondents) and laparoscopic subtotal hysterectomy (93% of respondents), despite the recent concerns surrounding power morcellation. Impact statement What is already known on this subject? There is a paucity of literature regarding laparoscopic specimen retrieval in gynaecology. In view of recent controversy pertaining to the potential upstaging of leiomyosarcoma with morcellation, other methods of specimen retrieval are gaining an importance. What do the results of this study add? This study shows that the umbilical port is the most commonly used port for specimen retrieval among UK gynaecologists and that most gynaecologists would not insert an additional port purely for specimen retrieval. Most respondents would still use power morcellation for a laparoscopic myomectomy and subtotal hysterectomy, despite the recent concerns over morcellation and its safety. What are the implications of these findings for clinical practice and/or further research? This paper demonstrates the need for development of a database of morcellation practices to enable analysis of both benefits and potential adverse outcomes. This paper will also encourage future research and the audit of specimen retrieval.

Development of a novel simulation model for assessment of laparoscopic camera navigation.

Laparoscopic camera navigation is vital to laparoscopic surgery, yet often falls to the most junior member of the surgical team who has limited laparoscopic operating experience. Previously published reports on simulation models fail to address qualitative scoring of movement, method of communication and correct physician location with respect to patient position. The purpose of this study was to develop and evaluate a novel laparoscopic camera navigation simulation model that addresses these deficiencies. A novel, low-cost laparoscopic camera navigational maze was constructed from pliable foam for use in a standard laparoscopic surgery box trainer. Participants (n=37) completed a camera navigation exercise by following a pre-recorded set of verbal instructions using correct anatomic terminology that is used in the operating room, to simulate an actual operating room experience of receiving verbal cues from senior surgeons. The sample group consisted of participants at various levels of Obstetrics and Gynecology training, representing novice to expert laparoscopists. Each trial was recorded with a multi-channel video camera. Performances were scored by a blinded evaluator for excess gross and fine camera movements as well as overt errors, including camera collisions and failure to follow directions. Our model demonstrated evidence of validity by discriminating performance by level of laparoscopic experience with a statistically significant decrease in number of movements and errors in experts compared to novices. A trend emerged toward improvement with each additional year of training, with reduced variability among performances in more experienced participants. This novel, low-cost box-trainer simulation model for laparoscopic camera navigation offers a mechanism for assessment of laparoscopic camera operation skills. Moreover, this model closely replicates operating room logistics and communication. Given the necessity for improved laparoscopic camera operation education, our model represents a unique, complementary tool to other laparoscopic simulation curricula.

An ex vivo liver training model continuously perfused to simulate bleeding for suture skills involved in laparoscopic liver resection: development and validity.

Suture skills are essential to laparoscopic liver resection. The current suture training models are not ideal enough. The aim of this study is to develop and verify a highly simulated-bleeding continuously perfused training model (CPTM) and to evaluate its training efficacy. CPTM was constructed using fresh lamb liver whose portal veins were perfused with red-dyed liquid gelatin. Construct validity of CPTMs was tested in 33 participants with three levels of laparoscopic experience (experts, intermediates, and novices) who were demanded to finish one superficial stitch and one deep stitch for suture hemostasis on CPTMs. The CPTMs were also evaluated by the experts. CPTMs were compared with dry box training models (DBTMs) regarding training efficacy among the novices who were assigned to DBTM and CPTM groups to, respectively, complete a 10-day training on CPTMs or DBTMs. Before and after their assignments, their superficial stitches were assessed by completion time, suture accuracy, and suture knot performance while their deep stitches by completion time and bleeding control. CPTM proved to be construct valid by both superficial and deep stitches. Significant differences were found regarding completion time (763, 271, 174s), suture accuracy (4.4, 1.8, 0.2mm), and suturing knot performance (12.1, 21.5, 22.0) for superficial stitches (p<0.001), as well as regarding completion time (807, 423, 277s) for deep stitches (p<0.001). Positive comments were given by all experts. CPTMs helped novices to acquire laparoscopic suture skills. Their training efficacy was significantly better than that of DBTMs (p<0.05). Learning curves of CPTM group plateaued at the sixth round for superficial stitches and at the seventh round for deep stitches. CPTM offers trainees a highly simulated-bleeding means to acquire advanced laparoscopic suture skills. The suture skills learned on CPTMs may improve significantly at the seventh round.

Validity of a cross-specialty test in basic laparoscopic techniques (TABLT)

BackgroundBox trainer systems have been developed that include advanced skills such as suturing. There is still a need for a portable, cheap training and testing system for basic laparoscopic techniques that can be used across different specialties before performing supervised surgery on patients. The aim of this study was to establish validity evidence for the Training and Assessment of Basic Laparoscopic Techniques (TABLT) test, a tablet‐based training system.MethodsLaparoscopic surgeons and trainees were recruited from departments of general surgery, gynaecology and urology. Participants included novice, intermediate and experienced surgeons. All participants performed the TABLT test. Performance scores were calculated based on time taken and errors made. Evidence of validity was explored using a contemporary framework of validity.ResultsSome 60 individuals participated. The TABLT was shown to be reliable, with an intraclass correlation coefficient of 0·99 (P < 0·001). ANOVA showed a difference between the groups with different level of experience (P < 0·001). The Bonferroni correction was used to confirm this finding. A Pearson's r value of 0·73 (P < 0·001) signified a good positive correlation between the level of laparoscopic experience and performance score. A reasonable pass–fail standard was established using contrasting groups methods.Conclusion TABLT can be used for the assessment of basic laparoscopic skills and can help novice surgical trainees in different specialties gain basic laparoscopic competencies.

A Spatial Secondary Task for Measuring Laparoscopic Mental Workload

The present study examined whether a spatial secondary task could distinguish among different levels of laparoscopic skill. Novices and surgeons with different levels of laparoscopic experience were asked to perform a peg transfer task on a laparoscopic simulator along with the secondary task. The results showed that novices performed more poorly than the surgeons on both the primary peg task and the secondary task. This pattern of results suggests that the primary task was more difficult for the novices leaving fewer attentional resources for the secondary task. Moreover, the results show that the spatial secondary task used in this study is sensitive to differences in mental resources required by individuals with different levels of laparoscopic surgical skill.

An “Intermediate Curriculum” for Advanced Laparoscopic Skills Training with Virtual Reality Simulation

Study Objective To estimate face and construct validity for a novel curriculum designed for intermediately skilled laparoscopic surgeons on a virtual reality simulator. It consists of 5 exercises that focus on training precision and coordination between both hands. Design Prospective study (Canadian Task Force II-2). Setting Three university hospitals and 4 teaching hospitals in the Netherlands. Subjects Residents, consultants, and laparoscopic experts (n = 69) in the fields of general surgery, gynecology, and urology participated. Participants were divided into 4 groups on the basis of their level of laparoscopic experience: resident, years 1–3 (n = 15); resident, years 4–6 (n = 17); consultant (n = 19); and laparoscopic experts (n = 18). Interventions Participants completed 3 runs of 5 exercises. The first run was an introduction, and the second and third runs were used for analysis. The parameters time, path length, collisions, and displacement were compared between groups. Afterward the participants completed a questionnaire to evaluate their laparoscopic experience and identify issues concerning the simulator and exercises. Measurements and Main Results The expert group was significantly faster (p <.05) than other groups in 4 of 5 exercises. The parameter displacement demonstrated a significant difference between the expert group and other groups in 2 of the 4 exercises in which this parameter was relevant (p <.05). In the questionnaire (n = 68), training capacity of the curriculum was scored with a median of 4 points on a 5-point Likert scale. Of all participants, 92.6% indicated that this curriculum is suitable as an addition to a basic skills module within their residency program. Conclusion Face and construct validity were estimated for an advanced virtual reality curriculum for intermediately skilled laparoscopic surgeons. The results indicate that the curriculum is suitable for training of residents and consultants and to assess and maintain their laparoscopic skills.

Automation of a suturing device for minimally invasive surgery

In minimally invasive surgery, hand suturing is categorized as a challenge in technique as well as in its duration. This calls for an easily manageable tool, permitting an all-purpose, cost-efficient, and secure viscerosynthesis. Such a tool for this field already exists: the Autosuture EndoStitch(®). In a series of studies the potential for the EndoStitch to accelerate suturing has been proven. However, its ergonomics still limits its applicability. The goal of this study was twofold: propose an optimized and partially automated EndoStitch and compare the conventional EndoStitch to the optimized and partially automated EndoStitch with respect to the speed and precision of suturing. Based on the EndoStitch, a partially automated suturing tool has been developed. With the aid of a DC motor, triggered by a button, one can suture by one-fingered handling. Using the partially automated suturing manipulator, 20 surgeons with different levels of laparoscopic experience successfully completed a continuous suture with 10 stitches using the conventional and the partially automated suture manipulator. Before that, each participant was given 1 min of instruction and 1 min for training. Absolute suturing time and stitch accuracy were measured. The quality of the automated EndoStitch with respect to manipulation was tested with the aid of a standardized questionnaire. To compare the two instruments, t tests were used for suturing accuracy and time. Of the 20 surgeons with laparoscopic experience (fewer than 5 laparoscopic interventions, n=9; fewer than 20 laparoscopic interventions, n=7; more than 20 laparoscopic interventions, n=4), there was no significant difference between the two tested systems with respect to stitching accuracy. However, the suturing time was significantly shorter with the Autostitch (P=0.01). The difference in accuracy and speed was not statistically significant considering the laparoscopic experience of the surgeons. The weight and size of the Autostitch have been criticized as well as its cable. However, the comfortable handhold, automatic needle change, and ergonomic manipulation have been rated positive. Partially automated suturing in minimally invasive surgery offers advantages with respect to the speed of operation and ergonomics. Ongoing work in this field has to concentrate on minimization, implementation in robotic systems, and development of new operation methods (NOTES).

Choosing the right physical laparoscopic simulator? comparison of LTS2000-ISM60 with MISTELS: validation, correlation, and user satisfaction

Background The LTS 2000-ISM60 (LTS; Realsim Systems, Alburquerque, NM, USA) is a computer enhanced video-laparoscopic training system. Our purpose was to validate the LTS and to correlate its scoring performance with that of the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS), a widely used and well-validated physical simulator. Methods Participants (n = 124) included medical students, residents, fellows, and attending surgeons from general surgery, gynecology, and urology in 3 Canadian universities. They were classified in groups based on laparoscopic experience: novice, intermediate, competent, and expert. Participants (n = 124) were tested on the LTS, and 74 were tested on both the LTS and the MISTELS. A user satisfaction questionnaire was completed after each performance. Results LTS metrics showed a progressive improvement in total scores according to academic level as well as level of laparoscopic experience ( P < .001). Good correlation was found between the LTS and the MISTELS ( r = .79). Level of user satisfaction was highest with LTS. Conclusions Based on laparoscopic experience and academic level, the LTS has a comparable discriminating capability for level of performance with that of the MISTELS. The higher degree of user satisfaction attributed to the LTS could justify its use as a training and assessment tool for surgical specialties.

Laparoscopic Decision Making: Impact of Preoperative Reading and Laparoscopic Experience

A competent laparoscopic surgeon requires good technical skills and good surgical judgment. The assessment of technical skills using bench models and simulators has been well studied. However, there has been a paucity of studies examining the cognitive aspects of surgery. We developed a novel tool to assess the procedural knowledge and higher level decision making required for successful laparoscopic nephrectomy. We assessed the effect of laparoscopic experience and the effect of self-preparation or preoperative reading on surgical decision making abilities using a novel assessment tool and methodology. A total of 17 novice and advanced urology residents were randomized to preoperative reading or no preoperative reading. Subjects viewed laparoscopic nephrectomy clips and verbalized their thought processes. Their performance was transcribed and blindly rated using a new surgical decision making rating scale. The correlation with overall surgical decision making rating scale score was good for years of training and moderate for the number of laparoscopic cases performed (r = 0.7 and 0.54, respectively, p < 0.05). Preoperative reading did not have a significant impact on the overall surgical decision making rating scale score (p > 0.05). However, when stratified by laparoscopic experience level (fewer than 10 cases), preoperative reading had a significant impact on the performance of novices with respect to the knowledge components of the procedure but not the judgment domain (each p > 0.05). Overall preoperative reading did not improve the surgical decision making rating scale. Novice procedural knowledge benefited from preoperative reading but not surgical judgment. The surgical decision making rating scale appears promising and it may have future implications for assessing surgical competency.

An Ergonomic Comparison of Robotic and Laparoscopic Technique: The Influence of Surgeon Experience and Task Complexity

This study compares the mental and physical workload of laparoscopic and robotic technique while performing simulated surgical tasks in a laboratory setting. Ten volunteer surgeons performed two tasks in a laparoscopic trainer using laparoscopic (LAP) and robotic (ROB) techniques. Outcome measures included: Task time, task-error, vertical/horizontal arm displacement, percent maximum electromyographic signal from the thenar, forearm flexor, and deltoid muscle compartments, skin conductance, and perceived difficulty and discomfort levels. A two-way repeated-measures ANOVA compared surgical technique and laparoscopic experience level (E = expert, N = novice). For the simple task, ROB technique was slower and had higher errors, and the surgeon's arm was more elevated. For the complex task, ROB electromyographic signal was lower. Stress was lower in both tasks for ROB, but the decrease was not statistically significant. Robotic technique appears slower and less precise than laparoscopic technique for simple tasks, but equally fast and possibly less stressful for complex tasks. Previous laparoscopic experience has a complex influence on the physical and mental adaptation to robotic surgery.

Beta Test Results of a New System Assessing Competence in Laparoscopic Surgery

There is currently a need for objective measures of surgical competence. Such measures should assess knowledge, judgment, and manual skills. The Fundamentals of Laparoscopic Surgery (FLS) program was developed by the Society of American Gastrointestinal and Endoscopic Surgeons to meet these criteria. The FLS assessment includes a multiple-choice cognitive test and a manual skills test. We present the results of validation studies of this novel assessment tool. Beta testing of the FLS examination was undertaken at 7 sites by 70 surgeons representing 4 levels of experience and training. Surgeons provided information about their prior experience and indicated a self-assessment of their laparoscopic competence. Results were assessed by ANOVA followed by orthogonal contrasts. Cognitive performance by training level: There was no difference between fellows and staff in percentage of questions answered correctly, but there was a discrepancy between junior and senior residents and between residents and senior surgeons (p < 0.01). Cognitive performance by laparoscopic experience quartiles: There were notable contrasts between the first and second quartiles of experience (p < 0.02) and between the third and fourth quartiles (p < 0.01). No marked difference was found between the second and third quartiles. Cognitive performance compared with self-assessment: Test results were substantially different (p < 0.01) between test-takers who assessed themselves as "better than average" and those who assessed themselves as "average" or "below average." Manual skills performance by training level: The major difference was found between junior residents versus senior residents, fellows or staff (p < 0.01). Manual skills performance by laparoscopic experience level: Differences were primarily seen between the first two quartiles and the last two quartiles of laparoscopic experience (p < 0.001). Manual skills performance compared with self-assessment: Those who assessed themselves as "above average" in laparoscopic skill performed markedly better than those indicating they had "average" or "below average" skill (p < 0.01). Beta test results for the FLS examination demonstrate satisfactory reliability, appropriate psychometric properties, and substantial initial validity. The FLS project is one of the first validated surgical education efforts to assess the competence of surgeons in a specific field.

Eye Motion Parameters Correlate with Level of Experience in Video-Assisted Surgery: Objective Testing of Three Tasks

Laparoscopic skills vary with experience and training; however, objective measures to ascertain the level of training have not yet been established. New technology allows noninterfering measurement of eye motion parameters that correlate with attention and distraction during visually oriented tasks. Our objective was to apply this new technology in the setting of video-assisted surgery to evaluate eye motion parameters among surgeons of varying experience. Subjects with various levels of laparoscopic experience (novice, intermediate, and expert) were fitted with a noninvasive, Food and Drug Administration approved, eye motion monitoring device. The device was used to measure and record parameters of eye motion, including saccadic rate (SR), standardized peak velocity (PV), standardized saccadic amplitude (SA), and the duration of gaze fixation (FD), during the performance of 3 basic laparoscopic tasks on a laparoscopic training station. A total of 24 subjects (3 groups of 8 each) participated in this study. Experience level was found to have a main significant effect on SR (P = 0.047) and PV (P = 0.028). Two-way ANOVA demonstrated that experience level approached significance for SA (P = 0.058) and FD (P = 0.055). The advancement of laparoscopic techniques and instrumentation relies, in part, on expanding the current understanding of operator/instrument interactions. This places an increasing demand on objective methods of monitoring such interactions during laparoscopy. Our study demonstrates a significant difference in eye motion parameters in surgeons with differing levels of experience. Further testing is needed in actual clinical settings to determine the importance of eye motion during surgery.

Assessing the learning curve for the acquisition of laparoscopic skills on a virtual reality simulator

The aim of this study was to develop summary metrics and assess the construct validity for a virtual reality laparoscopic simulator (LapSim) by comparing the learning curves of three groups with different levels of laparoscopic expertise. Three groups of subjects ('expert', 'junior', and 'naïve') underwent repeated trials on three LapSim tasks. Formulas were developed to calculate scores for efficiency ('time-error') and economy of 'motion' ('motion') using metrics generated by the software after each drill. Data (mean +/- SD) were evaluated by analysis of variance (ANOVA). Significance was set at p < 0.05. All three groups improved significantly from baseline to final for both 'time-error' and 'motion' scores. There were significant differences between groups in time error performances at baseline and final, due to higher scores in the 'expert' group. A significant difference in 'motion' scores was seen only at baseline. We have developed summary metrics for the LapSim that differentiate among levels of laparoscopic experience. This study also provides evidence of construct validity for the LapSim.

The influence of three-dimensional video systems on laparoscopic task performance.

Many laparoscopic surgeons feel constrained by the two-dimensional (2-D) view provided by video monitors. Video-eye-hand coordination is further complicated by the diminished tactile feedback blunted by elongated instruments. Video systems capable of receiving and displaying three-dimensional (3-D) images are now available for laparoscopy. First-generation 3-D systems have been marketed with the promise of significant time savings in laparoscopic procedures compared with 2-D optics. We assessed whether laparoscopic task performance was better in 2-D or 3-D among individuals with varying levels of laparoscopic experience. Five different tasks were performed in random order using both 2-D and 3-D technology by medical students (n = 10), inexperienced surgical residents (n = 10), and laparoscopic attending surgeons (n = 10). There was no significant difference in task performance between 2-D and 3-D among groups performing simple or difficult tasks, although suturing and knot-tying were performed 12% (p = 0.06) faster in 3-D by all groups. With repetition of tasks three times, the difference between the 2-D and 3-D systems was indistinguishable. Subjective assessment of the video systems by participants revealed that only 46% (p = 0.72) preferred working in three dimensions, despite 60% (p = 0.27) sensing more motor control in 3-D. Our results suggest that first-generation 3-D video systems offer no significant advantage to the novice or expert surgeon performing laparoscopic procedures. Further trials with the next generation of 3-D video systems and a larger sample size may support the trend favoring 3-D for more complex maneuvers, such as suturing and knot-typing.